power point taken from nelson 21st edition on spinal and peripheral nerve disease

1. University of Gondar
Ppt from Nelson 21st edition
On spinal and peripheral nerve disease in neonate
By Birhanu Alehegn
Sep 2021

2. 120.5 Spine and Spinal Cord
See also Chapter 729 .
Injury to the spine/spinal cord during birth is rare but can be devastating.
Strong traction exerted when the spine is hyperextended or when the direction of pull is
lateral, or forceful longitudinal traction on the trunk while the head is still firmly engaged
in the pelvis, especially when combined with flexion and torsion of the vertical axis, may
produce fracture and separation of the vertebrae.
Such injuries are most likely to occur when difficulty is encountered in delivering the
shoulders in cephalic presentations and the head in breech presentations.
The injury occurs most often at the level of the 4th cervical vertebra with cephalic
presentations and the lower cervical–upper thoracic vertebrae with breech presentations.
Transection of the cord may occur with or without vertebral fractures; hemorrhage and
edema may produce neurologic signs that are indistinguishable from those of transection,
except that they may not be permanent.

3. Areflexia, loss of sensation, and complete paralysis of voluntary motion occur below the
level of injury, although the persistence of a withdrawal reflex mediated through spinal
centers distal to the area of injury is frequently misinterpreted as representing voluntary
motion.
If the injury is severe, the infant, who from birth may be in poor condition because of
respiratory depression, shock, or hypothermia, may deteriorate
rapidly to death within several hours before any neurologic signs are obvious.
Alternatively, the course may be protracted, with symptoms and signs appearing at birth
or later in the 1st wk; Horner syndrome, immobility, flaccidity, and associated brachial
plexus injuries may not be recognized for several days.
Constipation may also be present. Some infants survive for prolonged periods, their initial
flaccidity, immobility, and areflexia being replaced after several weeks or months by rigid
flexion of the extremities, increased muscle tone, and spasms.
Apnea on day 1 and poor motor recovery by 3 mo are poor prognostic signs

4. The differential diagnosis of neonatal spine/spinal cord injury includes
amyotonia congenita and myelodysplasia associated with spina bifida occulta
spinal muscular atrophy (type 0),
spinal vascular malformations (e.g., arteriovenous malformation causing
hemorrhage or stroke), and
congenital structural anomalies (syringomyelia, hemangioblastoma)
US or MRI confirms the diagnosis
Treatment of the survivors is supportive, including home ventilation; patients often
remain permanently disabled
When a fracture or dislocation is causing spinal compression, the prognosis is related to
the time elapsed before the compression is relieved.

5. 120.6
Peripheral NerveInjuries
BrachialPalsy
Brachial plexus injury is a common problem, with an incidence of 0.6-4.6 per 1,000 live
births. Injury to the brachial plexus may cause paralysis of the upper part of the arm with
or without paralysis of the forearm or hand or, more often, paralysis of the entire arm.
These injuries occur in macrosomic infants and when lateral traction is exerted on the
head and neck during delivery of the shoulder in a vertex presentation, when the arms are
extended over the head in a breech presentation, or when excessive traction is placed on
the shoulders.
Approximately 45% of brachial plexus injuries are associated with shoulder dystocia.
In Erb-Duchenne paralysis the injury is limited to the 5th and 6th cervical nerves
The infant loses the power to abduct the arm from the shoulder, rotate the arm externally,
and supinate the forearm
The characteristic position consists of adduction and internal rotation of the arm with
pronation of the forearm

6. Power to extend the forearm is retained, but the biceps reflex is absent; the Moro reflex is
absent on the affected side (Fig. 120.10 ). The outer aspect of the arm may have some
sensory impairment
Power in the forearm and hand grasps is preserved unless the lower part of the plexus is
also injured; the presence of hand grasp is a favorable prognostic sign
When the injury includes the phrenic nerve, alteration in diaphragmatic excursion may
be observed with US, fluoroscopy, or as asymmetric elevation of the diaphragm on chest
radiograph.

7. FIG. 120.10Schematicrepresentation of the brachial plexuswithits terminal branches.The majorsitesof brachial plexusinjury
are shown.(Courtesyof Netter Images,Image ID 19943. www.netterimages.com.)
,

8. Klumpke paralysis is a rare form of brachial palsy in which injury to the 7th and 8th
cervical nerves and the 1st thoracic nerve produces a paralyzed hand and ipsilateral ptosis
and miosis (Horner syndrome ) if the sympathetic fibers of the 1st thoracic root are also
injured.
Mild cases may not be detected immediately after birth. Differentiation must be made
from cerebral injury; from fracture, dislocation, or epiphyseal separation of the humerus;
and from fracture of the clavicle.
MRI demonstrates nerve root rupture or avulsion.
Most patients have full recovery. If the paralysis was a result of edema and hemorrhage
around the nerve fibers, function should return within a few months; if it resulted from
laceration, permanent damage may result. Involvement of the deltoid is usually the most
serious problem and may result in shoulder drop secondary to muscle atrophy.
In general, paralysis of the upper part of the arm has a better prognosis than paralysis of
the lower part

9. Treatment consists of initial conservative management with monthly follow- up and a
decision for surgical intervention by 3 mo if function has not improved
Partial immobilization and appropriate positioning are used to prevent the development
of contractures
In upper arm paralysis, the arm should be abducted 90 degrees with external rotation at
the shoulder, full supination of the forearm, and slight extension at the wrist with the
palm turned toward the face
This position may be achieved with a brace or splint during the 1st 1-2 wk.
Immobilization should be intermittent throughout the day while the infant is asleep and
between feedings
In lower arm or hand paralysis, the wrist should be splinted in a neutral position and
padding placed in the fist
When the entire arm is paralyzed, the same treatment principles should be followed
 Gentle massage and range-of-motion exercises may be started by 7-10 days of age. Infants
should be closely monitored with active and passive corrective exercises

10. If the paralysis persists without improvement for 3 mo, neuroplasty, neurolysis, end-to-
end anastomosis, and nerve grafting offer hope for partial recovery
The type of treatment and the prognosis depend on the mechanism of injury and the
number of nerve roots involved
The mildest injury to a peripheral nerve (neurapraxia ) is caused by edema and heals
spontaneously within a few weeks
Axonotmesis is more severe and is a consequence of nerve fiber disruption with an intact
myelin sheath; function usually returns in a few months
Total disruption of nerves (neurotmesis ) or root avulsion is the most severe, especially if it
involves C5-T1; microsurgical repair may be indicated
Fortunately, most (75%) injuries are at the root level C5-C6, involve neurapraxia and
axonotmesis, and should heal spontaneously. Botulism toxin may be used to treat biceps-
triceps co-contractions

11. PhrenicNerve Paralysis
Phrenic nerve injury (3rd, 4th, 5th cervical nerves) with diaphragmatic paralysis must be
considered when cyanosis and irregular and labored respirations develop
Such injuries, usually unilateral, are associated with ipsilateral upper brachial plexus
palsies in 75% of cases
Because breathing is thoracic in type, the abdomen does not bulge with inspiration
Breath sounds are diminished on the affected side
The thrust of the diaphragm, which may often be felt just under the costal margin on the
normal side, is absent on the affected side
The diagnosis is established by US or fluoroscopic examination, which reveals elevation of
the diaphragm on the paralyzed side and seesaw movements of the 2 sides of the
diaphragm during respiration
It may also be apparent on chest or abdominal radiograph

12. Infants with phrenic nerve injury should be placed on the involved side and given oxygen
if necessary. Some may benefit from pressure introduced by continuous positive airway
pressure (CPAP) to expand the paralyzed hemidiaphragm
In extreme cases, mechanical ventilation cannot be avoided. Initially, intravenous feedings
may be needed; later, progressive gavage or oral feeding may be started, depending on the
infant's condition
Pulmonary infections are a serious complication. If the infant fails to demonstrate
spontaneous recovery in 1-2 mo, surgical plication of the diaphragm may be indicated.

13. Facial Nerve Palsy
Facial palsy is usually a peripheral paralysis that results from pressure over the facial
nerve in utero, during labor, or from forceps use during delivery. Rarely, it may result
from nuclear agenesis of the facial nerve
Peripheral facial paralysis is flaccid and, when complete, involves the entire side of the
face, including the forehead. When the infant cries, movement occurs only on the
nonparalyzed side of the face, and the mouth is drawn to that side.
On the affected side the forehead is smooth, the eye cannot be closed, the nasolabial fold is
absent, and the corner of the mouth droops.
Central facial paralysis spares the forehead (e.g., forehead wrinkles will still be apparent
on the affected side) because the nucleus that innervates the upper face has overlapping
dual innervation by corticobulbar fibers originating in bilateral cerebral hemispheres.
The infant with central facial paralysis usually has other manifestations of intracranial
injury, most often 6th nerve palsy from the proximity of the 6th and 7th cranial nerve
nuclei in the brainstem.

14. Prognosis depends on whether the nerve was injured by pressure or the nerve fibers were
torn; improvement occurs within a few weeks in the former case.
Care of the exposed eye is essential. Neuroplasty may be indicated when the paralysis is
persistent.
Facial palsy may be confused with absence of the depressor muscles of the mouth, which is
a benign problem or with variants of Möbius syndrome.
Other peripheral nerves are seldom injured in utero or at birth except when they are
involved in fractures or hemorrhage.